Trilogy Foundation
Trilogy Health Services Travel Questionnaire
If you are traveling to anywhere outside of the continental U.S., including Alaska, Hawaii, U.S. territories or other countries, please fill out the form below. A member of the Clinical Support team may be in contact with you to ensure that you take the proper precautions to keep your family, coworkers, and residents healthy! If you're planning multiple trips in the near future, please submit a new form for each trip.
Name
*
First
Last
Employee ID. If you are not an employee, please list 11111 in this space.
*
Location
*
Campus
Home Office
PCA Pharmacy
Paragon Rehabilitation
Trilogy Campus
*
Amber Manor Care Center
Arlington Place Health Campus
Ashford Place Health Campus
Aspen Place Health Campus
Autumn Woods Health Campus
Avalon Springs Health Campus
Bethany Pointe Health Campus
Blair Ridge Health Campus
Briar Hill Health Campus
BridgePointe Health Campus
Cedar Creek Health Campus
Cedar Ridge Health Campus
Clearvista Lake Health Campus
Cobblestone Crossings Health Campus
Covered Bridge Health Campus
Creasy Springs Health Campus
Cumberland Pointe Health Campus
Cypress Pointe Health Campus
Forest Glen Health Campus
Forest Park Health Campus
Forest Springs Health Campus
Franciscan Health Care Center
Genoa Retirement Village
Glen Oaks Health Campus
Glen Ridge Health Campus
Greenleaf Health Campus
Hampton Oaks Health Campus
Harrison's Crossing Health Campus
Harrison Springs Health Campus
Hearthstone Health Campus
The Oaks at Cascade
Highland Oaks Health Campus
Homewood Health Campus
Home Office
Mill Pond Health Campus
Morrison Woods Health Campus
North River Health Campus
Oakwood
Orchard Grove Health Campus
Orchard Pointe Health Campus
Owen Valley Health Campus
Paddock Springs
Park Terrace Health Campus
Prairie Lakes Health Campus
RidgeCrest Health Campus
RidgeWood Health Campus
River Pointe Health Campus
River Terrace Health Campus
RiverOaks Health Campus
Sanders Ridge Health Campus
Scenic Hills at the Monastery
Senior Living at Forest Ridge
Shelby Crossing Health Campus
Silver Oaks Health Campus
Smith's Mill Health Campus
Springhurst Health Campus
Springview Manor
Springhurst Pines
St. Andrews Health Campus
St. Charles Health Campus
St. Elizabeth Healthcare Center
St. Mary Healthcare Center
StoneBridge Health Campus
Stonecroft Health Campus
Stonegate Health Campus
Taylor Springs Health Campus
The Glen
The Heritage
The Lakes of Monclova
Novi Lakes Health Campus
The Lakes of Sylvania
The Legacy at English Station
The Legacy at Liberty Ridge
Waterford Crossing
The Meadows of Delphos
The Meadows of Kalida
The Meadows of Leipsic
The Meadows of Ottawa
The Oaks at Bethesda
The Oaks at Byron Center (replacement for Oaks at Cascade)
The Oaks at Northpointe
The Oaks at NorthPointe Woods
The Oaks at Woodfield
The Springs at Lafayette
The Springs at Stony Brook
The Springs of Lima
The Springs of Mooresville
The Springs of Richmond
The Villages at Historic Silvercrest
The Villages at Oak Ridge
The Willows at Bellevue
The Willows at Citation
The Willows at East Lansing
The Willows at Fritz Farm
The Willows at Hamburg
The Willows at Harrodsburg
The Willows at Howell
The Willows at Okemos
The Willows at Tiffin
The Willows at Willard
Thornton Terrace Health Campus
Triple Creek Retirement Community
Valley View Health Campus
Village Green Health Campus
Violet Springs Health Campus
Waterford Place Health Campus
Wellbrooke of Avon
Wellbrooke of Carmel
Wellbrooke of Crawfordsville
Wellbrooke of Kokomo
Wellbrooke of South Bend
Wellbrooke of Wabash
Wellbrooke of Westfield
West River Health Campus
Westlake Health Campus
Westport Place Health Campus
White Oak Health Campus
Wooded Glen
WoodBridge Health Campus
Woodmont Health Campus
Paragon
*
Home Office
Amber Manor Care Center
Arlington Place Health Campus
Ashford Place Health Campus
Aspen Place Health Campus
Autumn Woods Health Campus
Avalon Springs Health Campus
Bethany Pointe Health Campus
Blair Ridge Health Campus
Briar Hill Health Campus
BridgePointe Health Campus
Cedar Creek Health Campus
Cedar Ridge Health Campus
Clearvista Lake Health Campus
Cobblestone Crossing Health Campus
Covered Bridge Health Campus
Creasy Springs Health Campus
Cumberland Pointe Health Campus
Cypress Pointe Health Campus
Forest Glen Health Campus
Forest Park Health Campus
Forest Springs Health Campus
Franciscan Health Care Center
Genoa Retirement Village
Glen Oaks Health Campus
Glen Ridge Health Campus
Greenleaf Health Campus
Hampton Oaks Health Campus
Harrison Springs Health Campus
Harrison's Crossing Health Campus
Hearthstone Health Campus
Highland Oaks Health Center
Homewood Health Campus
Louisville Springhurst Combined
Mill Pond Health Campus
Morrison Woods Health Campus
North River Health Campus
Novi Lakes Health Campus
Oakwood Health Campus
Orchard Grove Health Campus
Orchard Pointe Health Campus
Owen Valley Health Campus
Paddock Springs
Park Terrace Health Campus
Prairie Lakes Health Campus
RidgeCrest Health Campus
RidgeWood Health Campus
River Pointe Health Campus
River Terrace Health Campus
RiverOaks Health Campus
Sanders Ridge Health Campus
Scenic Hills at the Monastery
Senior Living at Forest Ridge
Shelby Crossing Health Campus
Silver Oaks Health Campus
Smith’s Mill Health Campus
Springhurst Health Campus
Springview Manor
St. Andrews Health Campus
St. Charles Health Campus
St. Elizabeth Healthcare Center
St. Mary Healthcare Center
Stonebridge Health Campus
Stonecroft Health Campus
Stonegate Health Campus
Taylor Springs Health Campus
The Glen
The Heritage
The Lakes of Monclova Health Campus
The Lakes of Sylvania
The Legacy at English Station - AL
The Legacy at Liberty Ridge - AL
The Meadows of Delphos
The Meadows of Kalida
The Meadows of Leipsic
The Meadows of Ottawa
The Oaks at Bethesda
The Oaks at Byron Center
The Oaks at Northpointe
The Oaks at NorthPointe Woods
The Oaks at Woodfield
The Springs at Lafayette
The Springs at Stony Brook
The Springs of Lima
The Springs Of Mooresville
The Springs Of Richmond
The Villages at Historic Silvercrest
The Villages at Oak Ridge
The Willows at Bellevue
The Willows at Citation
The Willows at East Lansing
The Willows at Fritz Farm
The Willows at Hamburg
The Willows at Harrodsburg
The Willows at Howell
The Willows at Okemos
The Willows at Tiffin
The Willows at Willard
Thornton Terrace Health Campus
Triple Creek Retirement Community
Valley View Health Campus
Village Green Health Campus
Violet Springs Health Campus
Waterford Crossing Health Campus
Waterford Crossing Health Campus
Waterford Place Health Campus
Wellbrooke of Avon
Wellbrooke of Carmel
Wellbrooke of Crawfordsville
Wellbrooke of Kokomo
Wellbrooke of South Bend
Wellbrooke of Wabash
Wellbrooke of Westfield
West River Health Campus
Westlake Health Campus
Westport Place Health Campus
White Oak Health Campus
WoodBridge Health Campus
Wooded Glen
Woodmont Health Campus
Good Shepherd Village
Westminster Village
Logan Acres Care Center
EKY Veterans Home
WKY Veterans Home
South Cove Manor at Quincy Point
Thompson Hood Veterans Center
Westbury McDonough
Witham Hospital
Hartsfield Village
Westbury Conyers Health & Rehabilitation Center
Brightmoor Health Care, Inc.
Liberty Heights
Radcliff Veterans Center
Westbury Medical - Jackson
La Vida Llena
United Methodist Village
Friendship Health and Rehab
The Neighborhood at Rio Rancho
PCA Pharmacy
*
PCA Louisville
PCA Choice (Ohio)
PCA Curo (Michigan)
PCA Indiana
PCA Iowa
PCA Mission (Pennsylvania)
PCA NuScriptRx Nashville
PCA Southern Indiana
PCA Tampa
Select the Country You Will be Visiting.
*
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte D'Ivoire
Croatia
Cuba
Cyprus
Czech Republic (Czechia)
Democratic People's Republic of Korea
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia (Federated States of)
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of Korea
Republic of Moldova
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
State of Palestine
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Tajikistan
Thailand
Republic of North Macedonia
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United Republic of Tanzania
United States of America
Uruguay
Uzbekistan
Vanuatu
Venezuela (Bolivarian Republic of)
Vietnam
Yemen
Zambia
Zimbabwe
US Virgin Island
If you are visiting multiple countries, please list all countries here.
Select the State You Will Be Visiting
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
If you are visiting multiple states, please list all states here.
Date of your depature
*
MM
/
DD
/
YYYY
Date of your return
*
MM
/
DD
/
YYYY
How are you travelling to your destination?
*
Plane
Car
I'm going on a cruise
N/A - I'm staying home
If you are travelling by plane, please list the airports you will utilize.
*
If you are going on a cruise, please list the ports you will visit.
*
Phone Number
*
###
-
###
-
####
Please provide a number our Clinical Support team can use to reach you.
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